Committee in Carcinogenicity of Chemicals in Food, Consumer Products and the Environment (COC)
Lay Member (EC13-07) 
Application form

Thank you for your interest in this appointment.  This form can be completed on your own PC, and returned by email to appointments.team@dh.gsi.gov.uk  with the above reference in the subject field. If completing by hand, please use black ink to assist with photocopying. This form should be returned, together with Annex A to the Department of Health Appointments Team with your CV and any continuation sheets.

The Department of Health is committed to ensuring that all appointments are made in a way that is open and fair to all applicants and all appointments are made on merit.

Your personal details

Surname		
First name		
Title				
Honours				
		
Home address

County		
Postcode		
Contacts	Home Phone	Mobile	
	Email		

Details of current or most recent post		

Specific Expertise

The information pack provides details of the criteria sought for the Lay Member post. 

This section gives you the opportunity to provide evidence to support how you meet all of the relevant criteria identified based on your professional/personal experience. 

Essential: Please provide evidence of being a good communicator with sound judgement.

	
Essential: Please demonstrate your ability to contribute to the work of the COC.

	
Essential:  Please demonstrate your ability to represent the view of an interested layman.

	
Essential:  Please demonstrate how you would be independent of the Government and industry.

	
Desirable: Please demonstrate your experience of committee membership.  

	
Desirable: Please demonstrate your experience of risk assessment and decision making processes.

	

Your CV

You may enclose a brief, up to date CV (no more than 2 sides of A4) outlining your employment history, any relevant voluntary work, public service or other experience, together with any relevant professional, academic or vocational qualification. 

Declaration of interests and ensuring public confidence

Do you have any business or personal interests that might be relevant to the work of COC and which could lead to a real or perceived conflict of interest were you to be appointed? If yes, please provide details below.

No			Yes		

Please specify below if you are a civil servant, employed by one of the Department’s Executive Agencies. This may be following structural changes as part of the recent health and care reforms. Although we do not wish to prevent employees of the Department’s Executive Agencies applying for these posts, we need to be aware of any potential conflicts of interest. 

Should you be successful in your application, is there anything about your professional history, if brought into the public domain, may cause embarrassment or disrepute to the organisation?

No			Yes		

If yes, please give details below (Failure to disclose such information could result in an appointment being terminated):

	

Sectoral background 

Do you consider your sectoral background to be?

Mostly private		Mostly Civil Service		Mostly wider public service		Mostly third sector		Mixed 		

References

Please provide details of two referees who will support your application, at least one of whom must be from a “line management capacity” related to your most recent professional and / or voluntary activity. They will be expected to have authorative and personal knowledge of your achievements/competencies. The referees will be approached only if you are invited for interview.

Name	
		Name		
Address			Address		
Postcode			Postcode		
Home Phone			Home Phone		
Mobile			Mobile		
E-mail			E-mail		
Relationship	
		Relationship		
Tick to indicate if this is from a line manager capacity			Tick to indicate if this is from a line manager capacity		

How you found out about this post

To help us target our recruitment activity effectively and publicise posts in the future, it would be helpful if you could let us know how you found out about the vacancy. Please provide details below.

Code of Conduct

All members on appointment are required to abide by the Code of Practice for Scientific Advisory Committees (CoPSAC):
http://www.bis.gov.uk/assets/BISPartners/GoScience/Docs/C/11-1382-code-of-practice-scientific-advisory-committees.pdf.
Please confirm that you have read and understood the standards of probity required by appointees as outlined in CoPSAC.

No			Yes		

Declaration

To the best of my knowledge and belief, the information given in this form is complete and correct. I have considered and understood any criteria for disqualification from appointment and I am not disqualified. I understand that if I am appointed and any of the information I have provided is subsequently found to be untrue then my appointment may be terminated. I confirm and accept these conditions.

No			Yes		

	Signature
			Date